Efficacy of Integrated Exposure Therapy vs Integrated Coping Skills Therapy for Comorbid Posttraumatic Stress Disorder and Alcohol Use Disorder: A Randomized Clinical Trial

Norman, Sonya B.; Trim, Ryan; Haller, Moira; Davis, Brittany C.; Myers, Ursula S.; Colvonen, Peter J.; Blanes, Erika; Lyons, Robert; Siegel, Emma Y.; Angkaw, Abigail C.; Norman, Gregory J.; Mayes, Tina

doi:10.1001/jamapsychiatry.2019.0638

Cited by 137Posttraumatic Stress Disorder ResearchSubstance Abuse Treatment and OutcomesPsychotherapy Techniques and Applications

Efficacy of Integrated Exposure Therapy vs Integrated Coping Skills Therapy for Comorbid Posttraumatic Stress Disorder and Alcohol Use Disorder: A Randomized Clinical Trial

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Norman, Sonya B., Trim, Ryan, Haller, Moira, Davis, Brittany C., Myers, Ursula S., Colvonen, Peter J., Blanes, Erika, Lyons, Robert +4 more·2019·JAMA Psychiatry

DOI 10.1001/jamapsychiatry.2019.0638PMC PMC6487906

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Abstract

Importance: Co-occurrence of posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) is common and associated with psychiatric and functional problems. Understanding whether exposure therapy is tolerable and efficacious for treating PTSD and AUD is critical to ensure that best practice treatments are available. Objective: To compare the efficacy of integrated (ie, targeting both PTSD and alcohol use) prolonged exposure (I-PE) therapy with present-centered integrated coping skills (I-CS) therapy, a more commonly available treatment, in reducing PTSD symptoms and alcohol use. Design, Setting, and Participants: This prospective randomized clinical trial with masked assessments considered 186 veterans seeking Veterans Affairs mental health services. A total of 119 veterans with PTSD and AUD were randomized. Data were collected from February 1, 2013, to May 31, 2017, before treatment, after treatment, and at 3- and 6-month follow-ups. Intention-to-treat analyses were performed. Interventions: Veterans underwent I-PE (Concurrent Treatment of PTSD and Substance Use Disorder Using Prolonged Exposure) or I-CS (Seeking Safety) therapy. Main Outcomes and Measures: A priori planned outcomes were PTSD symptoms (Clinician Administered PTSD Scale for DSM-5) and percentage of heavy drinking days (Timeline Follow-Back) before treatment, after treatment, and at 3- and 6-month follow-ups. Results: A total of 119 veterans (mean [SD] age, 41.6 [12.6] years; 107 [89.9%] male) were randomized. Linear mixture models found that PTSD symptoms decreased in both conditions, with a significantly greater decrease for I-PE treatment compared with I-CS treatment (treatment × time interaction, -2.83; F3,233.1 = 4.92; Cohen d = 0.41; P = .002). The percentage of heavy drinking days improved in both conditions but was not statistically different between I-PE and I-CS treatment (treatment × time interaction, 1.8%; F3,209.9 = 0.18; Cohen d = 0.04; P = .91). Conclusions and Relevance: The I-PE arm had a greater reduction in PTSD symptoms than the I-CS arm and comparable drinking decreases. The study provides evidence that exposure therapy is more efficacious in treating PTSD than a more commonly available integrated treatment without exposure for comorbid PTSD and AUD. Trial Registration: ClinicalTrials.gov identifier: NCT01601067.

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PTSD/Substance Use Disorder Comorbidity: Treatment Options and Public Health Needs
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Does exposure exacerbate symptoms in veterans with PTSD and alcohol use disorder?
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Estimating posttraumatic stress disorder severity in the presence of differential item functioning across populations, comorbidities, and interview measures: Introduction to Project Harmony
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Minority participation in randomized controlled trials for prolonged exposure therapy: A systematic review of the literature
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Stabilisation and Phase-Orientated Psychological Treatment for Posttraumatic Stress Disorder – A Systematic Review and Meta-Analysis
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Psychological treatment of PTSD with comorbid substance use disorder (SUD): expert recommendations of the European Society for Traumatic Stress Studies (ESTSS)
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Trauma-focused treatment for comorbid post-traumatic stress and substance use disorder
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Cognitive Processing Therapy or Relapse Prevention for comorbid Posttraumatic Stress Disorder and Alcohol Use Disorder: A randomized clinical trial
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Comparing Exposure‐ and Coping Skills–Based Treatments on Trauma‐Related Guilt in Veterans With Co‐Occurring Alcohol Use and Posttraumatic Stress Disorders
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A randomized controlled trial evaluating integrated versus phased application of evidence-based psychotherapies for military veterans with comorbid PTSD and substance use disorders
Kehle‐Forbes, S., Chen, S., Polusny, M. A., Lynch, K. G., Koffel, E., Ingram, E. P., Foa, E. B., Horn, D. H. A. V., Drapkin, M. L., Yusko, D. A., et al. (2019) · Drug and Alcohol Dependence · doi:10.1016/j.drugalcdep.2019.107647 · Cited by 22 · see citing works
Substance use predictors of attendance among veterans in integrated PTSD and alcohol use disorder treatment
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What’s in a name? A data-driven method to identify optimal psychotherapy classifications to advance treatment research on co-occurring PTSD and substance use disorders
Hien, D. A., Fitzpatrick, S., Saavedra, L. M., Ebrahimi, C. T., Norman, S. B., Tripp, J., Ruglass, L. M., Lopez-Castro, T., Killeen, T. K., Back, S. E., et al. (2022) · European Journal of Psychotraumatology · doi:10.1080/20008198.2021.2001191 · Cited by 18 · see citing works
Self-medicating low mood with alcohol use: Examining the role of frequency of alcohol use, quantity consumed and context of drinking
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Differential symptom weighting in estimating empirical thresholds for underlying PTSD severity: Toward a “platinum” standard for diagnosis?
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Examining sleep over time in a randomized control trial comparing two integrated PTSD and alcohol use disorder treatments
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Conducting Prolonged Exposure for PTSD During the COVID-19 Pandemic: Considerations for Treatment
Fina, B. A., Wright, E. C., Rauch, S. A. M., Norman, S. B., Acierno, R. E., Cuccurullo, L. J., Dondanville, K. A., Moring, J. C., Brown, L. A., & Foa, E. B. (2020) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2020.09.003 · Cited by 17 · see citing works
Trauma-related guilt and posttraumatic stress disorder symptoms in military veterans: The role of psychological inflexibility
Kachadourian, L. K., Lyons, R. C., Davis, B. C., Haller, M. M., & Norman, S. B. (2021) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2021.02.022 · Cited by 17 · see citing works
Within-treatment clinical markers of dropout risk in integrated treatments for comorbid PTSD and alcohol use disorder
Kline, A. C., Panza, K. E., Harlé, K. M., Angkaw, A. C., Trim, R. S., Back, S. E., & Norman, S. B. (2021) · Drug and Alcohol Dependence · doi:10.1016/j.drugalcdep.2021.108592 · Cited by 17 · see citing works
A randomized clinical trial of prolonged exposure and applied relaxation for the treatment of Latinos with posttraumatic stress disorder
Vera, M., Obén, A., Juarbe, D., Hernández, N., Kichic, R., & Hembree, E. (2021) · Journal of Traumatic Stress · doi:10.1002/jts.22773 · Cited by 12 · see citing works
Prolonged Exposure Therapy
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Cortisol as a Biomarker of Alcohol Use in Combat Veterans: A Literature Review and Framework for Future Research
Szabo, Y. Z., Breeding, T., Hejl, C., Guleria, R. S., Nelson, S. M., & Zambrano‐Vazquez, L. (2020) · Journal of Dual Diagnosis · doi:10.1080/15504263.2020.1771504 · Cited by 15 · see citing works
The Role of Affect in Psychosocial Treatments for Substance Use Disorders
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Examining the role of social support in treatment for co-occurring substance use disorder and posttraumatic stress disorder
Jarnecke, A. M., Saraiya, T. C., Brown, D. G., Richardson, J., Killeen, T., & Back, S. (2022) · Addictive Behaviors Reports · doi:10.1016/j.abrep.2022.100427 · Cited by 12 · see citing works
PTSD symptom heterogeneity and alcohol-related outcomes in U.S. military veterans: Indirect associations with coping strategies
Palmisano, A. N., Norman, S. B., Panza, K. E., Petrakis, I. L., & Pietrzak, R. H. (2021) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2021.102496 · Cited by 13 · see citing works
Residual Symptoms of Posttraumatic Stress Disorder and Alcohol Use Disorder Following Integrated Exposure Treatment Versus Coping Skills Treatment.
Tripp, J. C., Angkaw, A., Schnurr, P., Trim, R. S., Haller, M., Davis, B. C., & Norman, S. B. (2020) · Journal of Traumatic Stress · doi:10.1002/jts.22552 · Cited by 13 · see citing works
PTSD as a Risk Factor Predicting Polydrug Use: A Dual Systems of Self-Control Mediation Model
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Treating posttraumatic stress disorder and alcohol use disorder comorbidity: Current pharmacological therapies and the future of MDMA-integrated psychotherapy
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Cannabis use and trauma-focused treatment for co-occurring posttraumatic stress disorder and substance use disorders: A meta-analysis of individual patient data
Hill, M. L., Kline, A. C., Saraiya, T. C., Gette, J., Ruglass, L. M., Norman, S. B., Back, S. E., Saavedra, L. M., Hien, D. A., & Morgan-López, A. A. (2024) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2024.102827 · Cited by 11 · see citing works
PTSD improvement and substance use disorder treatment utilization in veterans: Evidence from medical record data
Salas, J., Norman, S. B., Tuerk, P. W., van den Berk‐Clark, C., Cohen, B. E., Schneider, D., Chard, K. M., Lustman, P. J., Schnurr, P. P., Friedman, M. J., et al. (2020) · Drug and Alcohol Dependence · doi:10.1016/j.drugalcdep.2020.108365 · Cited by 11 · see citing works
Substance Use after Completion of an Intensive Treatment Program with Concurrent Treatment for Posttraumatic Stress Disorder and Substance Use among Veterans: Examining the Role of PTSD Symptoms
Watkins, L. E., Patton, S. C., Wilcox, T., Drexler, K. P. G., Rauch, S. A. M., & ROTHBAUM, B. O. (2023) · Journal of Dual Diagnosis · doi:10.1080/15504263.2023.2290167 · Cited by 11 · see citing works
Concurrent Treatment of Posttraumatic Stress Disorder and Alcohol Use Disorder in Women
Persson, A., Axén, Å., Capusan, A. J., Magnusson, Å., & Heilig, M. A. (2025) · JAMA Network Open · doi:10.1001/jamanetworkopen.2025.21087 · Cited by 10 · see citing works
Negative Affect Mediates the Association between Posttraumatic Cognitions and Craving in Veterans with Posttraumatic Stress Disorder and Alcohol Use Disorder
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Mental Health Clinician Practices and Perspectives on Treating Adults with Co-Occurring Posttraumatic Stress and Substance Use Disorders
Vujanovic, A. A., Back, S. E., Leonard, S. J., Zoller, L., Kaysen, D. L., Norman, S. B., Flanagan, J. C., Schmitz, J. M., & Resick, P. A. (2023) · Journal of Dual Diagnosis · doi:10.1080/15504263.2023.2260338 · Cited by 11 · see citing works
Heart rate during sleep in PTSD patients: Moderation by contact with a service dog
Woodward, S. H., Jamison, A. L., Gala, S., Lawlor, C., Villasenor, D., Tamayo, G. C., & Puckett, M. (2023) · Biological Psychology · doi:10.1016/j.biopsycho.2023.108586 · Cited by 9 · see citing works
Resting-state connectivity subtype of comorbid PTSD and alcohol use disorder moderates improvement from integrated prolonged exposure therapy in Veterans
Stout, D. M., Harlé, K. M., Norman, S. B., Simmons, A. N., & Spadoni, A. D. (2021) · Psychological Medicine · doi:10.1017/s0033291721001513 · Cited by 9 · see citing works
Trauma-Informed Organizational Dynamics and Client Outcomes in Concurrent Disorder Treatment
Shier, M. L., & Turpin, A. (2021) · Research on Social Work Practice · doi:10.1177/10497315211013908 · Cited by 10 · see citing works
Subgroups of comorbid PTSD and AUD in U.S. military veterans predict differential responsiveness to two integrated treatments: A latent class analysis
Panza, K. E., Kline, A. C., Norman, G. J., Pitts, M., & Norman, S. B. (2021) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2021.02.061 · Cited by 9 · see citing works
Examining attendance patterns across integrated therapies for posttraumatic stress disorder and alcohol use disorder
Straus, E., Worley, M. J., Lyons, R. C., Kline, A. C., Tripp, J. C., Davis, B. C., Haller, M. M., Angkaw, A. C., Trim, R. S., & Norman, S. B. (2021) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2021.102498 · Cited by 9 · see citing works
A randomized comparison trial of culturally adapted HIV prevention approaches for Native Americans reducing trauma symptoms versus substance misuse: The Healing Seasons protocol
Pearson, C. R., Kaysen, D., Huh, D., Bedard-Gillgan, M., Walker, D., Marin, R., & Saluskin, K. (2020) · Contemporary Clinical Trials · doi:10.1016/j.cct.2020.106070 · Cited by 9 · see citing works
Expectation of pain and relief: A dynamical model of the neural basis for pain-trauma co-morbidity
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COPE and oxytocin for the treatment of co-occurring PTSD and alcohol use disorder: Design and methodology of a randomized controlled trial in U.S. military veterans
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The lived experiences and treatment needs of women with opioid use disorder and posttraumatic stress symptoms: A mixed methods study
Saraiya, T. C., Helpinstill, S., Gray, D., Hien, D. A., Brady, K. T., Hood, C. O., & Back, S. E. (2024) · Journal of Substance Use and Addiction Treatment · doi:10.1016/j.josat.2024.209344 · Cited by 8 · see citing works
Healthcare utilization and readiness outcomes among soldiers with post-deployment at-risk drinking, by multimorbidity class
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Patient‐ and therapist‐rated alliance predict improvements in posttraumatic stress disorder symptoms and substance use in integrated treatment
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A Comparison of Cognitive Processing Therapy and Seeking Safety for the Treatment of Posttraumatic Stress Disorder in Veterans
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Decreases in psychiatric symptoms persist following exposure-based group therapy for sexual violence victimization among incarcerated women.
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Temporal dynamics of symptom change among veterans receiving an integrated treatment for posttraumatic stress disorder and substance use disorders
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Predictors of Treatment Completion among Women Receiving Integrated Treatment for Comorbid Posttraumatic Stress and Substance Use Disorders
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The association of engagement in substance use treatment with negative separation from the military among soldiers with post-deployment alcohol use disorder
Gray, J. C., Larson, M. J., Moresco, N., Ritter, G. A., Dufour, S. C., Milliken, C. S., & Adams, R. S. (2021) · Drug and Alcohol Dependence · doi:10.1016/j.drugalcdep.2021.108647 · Cited by 7 · see citing works
Does Group Size Matter? Group Size and Symptom Reduction among Incarcerated Women Receiving Psychotherapy following Sexual Violence Victimization
Dueweke, A. R., Higuera, D. E., Zielinski, M. J., Karlsson, M. E., & Bridges, A. J. (2022) · International Journal of Group Psychotherapy · doi:10.1080/00207284.2021.2015601 · Cited by 6 · see citing works
Impact of three variants of prolonged exposure therapy on comorbid diagnoses in patients with childhood abuse-related PTSD
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Pharmacological treatments for co-occurring PTSD and substance use disorders: A systematic review
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Changes in positive and negative affect following prolonged exposure for PTSD comorbid with alcohol use disorder: Secondary analysis of a randomized clinical trial
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Comparative effectiveness of trauma-focused and non-trauma-focused psychotherapy for PTSD among veterans with comorbid substance use disorders: Protocol & rationale for a randomized clinical trial
Kehle‐Forbes, S., Nelson, D. B., Norman, S. B., Schnurr, P. P., Shea, M. T., Ackland, P. E., Meis, L. A., Possemato, K., Polusny, M. A., Oslin, D. W., et al. (2022) · Contemporary Clinical Trials · doi:10.1016/j.cct.2022.106876 · Cited by 6 · see citing works
Direct and Indirect Exposure to Trauma, Posttraumatic Stress Disorder Symptoms, and Poor Subjective Sleep Quality in Patients with Substance Use Disorder
ten Holt, J. A., van Emmerik, A., Blanken, P., Borgdorff, J. E., Holt, P. P. C. T., Kok, R., Mouthaan, J., Pieterse, B., & van den Berg, J. F. (2022) · Psychiatry and Clinical Psychopharmacology · doi:10.5152/pcp.2022.22368 · Cited by 6 · see citing works
A Randomized Clinical Trial of Prolonged Exposure Therapy With and Without Topiramate for Comorbid PTSD and Alcohol Use Disorder
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Motives for substance use and 6‐month substance use outcomes among detoxification patients with a history of physical or sexual abuse or posttraumatic stress disorder
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Psychosocial functioning in integrated treatment of co-occurring posttraumatic stress disorder and alcohol use disorder
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Substance Use, PTSD Symptoms, and Suicidal Ideation Among Veteran Psychiatry Inpatients: A Latent Class Trajectory Analysis
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Gender Difference in Substance Use and Psychiatric Outcomes Among Dually Diagnosed Veterans Treated in Specialized Intensive PTSD Programs
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Addressing co-occurring suicidal thoughts and behaviors and posttraumatic stress disorder in evidence-based psychotherapies for adults: A systematic review.Preprint
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Improving Engagement in Residential Treatment for Substance Use Disorders: An Integrated Care Quality Improvement Project for Individuals With Mental Health and Substance Use Disorders
Ramey, F. R., Stevenson, E. L., Derouin, A. L., Sharma, S., & Ruhiu, M. (2024) · The Journal for Nurse Practitioners · doi:10.1016/j.nurpra.2024.105174 · Cited by 4 · see citing works
Neural affective mechanisms associated with treatment responsiveness in veterans with PTSD and comorbid alcohol use disorder
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Comparison of Accelerated Resolution Therapy for PTSD Between Veterans With and Without Prior PTSD Treatment
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Imaginal exposure processing during Concurrent Treatment of PTSD and Substance Use Disorders using Prolonged Exposure (COPE) therapy: Examination of linguistic markers of cohesiveness
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A randomized controlled trial testing theory‐driven enhancements to increase the efficacy of and engagement in a brief cognitive‐behavioural therapy text‐message intervention for co‐occurring posttraumatic stress disorder symptoms and alcohol misuse
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Concerns About Potential Bias in a Randomized Clinical Trial of Integrated Prolonged Exposure Therapy vs Seeking Safety Integrated Coping Skills Therapy—Reply
Norman, S. B. (2019) · JAMA Psychiatry · doi:10.1001/jamapsychiatry.2019.2229 · Cited by 3 · see citing works
A Randomized Comparison Trial Testing Two Culturally Adapted HIV Prevention Approaches for Native Americans Reducing Trauma Symptoms Versus Substance Misuse
Pearson, C. R., Huh, D., Bedard‐Gilligan, M. A., Walker, D. D., Marín, R. A., Saluskin, K., & Kaysen, D. L. (2025) · AIDS and Behavior · doi:10.1007/s10461-025-04777-w · Cited by 2 · see citing works
Randomised controlled trial to compare the efficacy of integrated cognitive-behavioural therapy (COPE-A) for substance use and traumatic stress among adolescents and young adults delivered via telehealth versus in person: trial protocol
Mills, K. L., Winter, V., Cobham, V. E., Peach, N., Arunogiri, S., Chatterton, M. L., Bendall, S., Back, S. E., Perrin, S. G., & Brady, K. T. (2025) · BMJ Open · doi:10.1136/bmjopen-2025-102710 · Cited by 2 · see citing works
The Role of Posttraumatic Cognitions in Integrated Treatments for Co-Occurring Posttraumatic Stress Disorder and Alcohol Use Disorder
Lyons, R. C., Helm, J. L., Luciano, M. T., Haller, M. M., & Norman, S. B. (2022) · Psychological Trauma Theory Research Practice and Policy · doi:10.1037/tra0001540 · Cited by 2 · see citing works
Nursing Interventions in the Management of Mental Health and Alcohol Use Disorders: A Comprehensive Review
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The Genetics of Alcohol Use Disorder
Wagner, J., Bell, A. S., Jung, J., & Lohoff, F. W. (2023) · Springer eBooks · doi:10.1007/978-3-031-32483-3_32 · Cited by 2 · see citing works
Concerns About Potential Bias in a Randomized Clinical Trial of Integrated Prolonged Exposure Therapy vs Seeking Safety Integrated Coping Skills Therapy
Najavits, L. M. (2019) · JAMA Psychiatry · doi:10.1001/jamapsychiatry.2019.2226 · Cited by 2 · see citing works
Treating Comorbid Posttraumatic Stress Disorder and Substance Use Disorder
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Evidence of physical deconditioning during psychiatric hospitalization in a Veteran sample
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A review of Seeking Safety’s effects on reducing PTSD symptoms and substance use: A best practice, but not a better one?
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Residual Symptoms of Posttraumatic Stress Disorder and Alcohol Use Disorder Following Integrated Exposure Treatment Versus Coping Skills Treatment.
Tripp, J. C., Angkaw, A., Schnurr, P., Trim, R. S., Haller, M., Davis, B. C., & Norman, S. B. (2020) · Journal of Traumatic Stress · doi:10.1002/jts.22552 · Cited by 13 · see citing works

Authors: Norman, S. B., Trim, R., Haller, M., Davis, B. C., Myers, U. S., Colvonen, P. J., Blanes, E., Lyons, R., Siegel, E. Y., Angkaw, A. C., Norman, G. J., & Mayes, T.
Affiliations: University of California San Diego (US)
James A. Haley Veterans' Hospital (US)
Ralph H. Johnson VA Medical Center (US)
VA San Diego Healthcare System (US)
San Diego State University (US)
The University of Texas at Austin (US)
ORCID: Norman, Sonya B.
Trim, Ryan
Davis, Brittany C.
Myers, Ursula S.
Colvonen, Peter J.
Lyons, Robert
Siegel, Emma Y.
Angkaw, Abigail C.
Norman, Gregory J.
Mayes, Tina
Venue: JAMA Psychiatry
Publisher: American Medical Association (AMA)
Published: 2019-08-01
Volume: 76
Issue: 8
Pages: 791
ISSN: 2168-622X (ISSN-L)
DOI: 10.1001/jamapsychiatry.2019.0638
PMC: PMC6487906
OpenAlex: W2942415626
Cited by: 136
References: 56
Citations by year: 2026: 14 · 2025: 15 · 2024: 15 · 2023: 18 · 2022: 21 · 2021: 27 · 2020: 23 · 2019: 3
FWCI: 21.61
Type: journal article
Language: en
Open access: bronze
doi.org
Locations: JAMA Psychiatry (publishedVersion)
PubMed Central (publishedVersion)
PubMed (publishedVersion)
Funders: Clinical Science Research and Development
National Institute on Alcohol Abuse and Alcoholism (T32AA013525)
Topics: Social Sciences › Psychology › Clinical Psychology › Posttraumatic Stress Disorder Research
Health Sciences › Medicine › Epidemiology › Substance Abuse Treatment and Outcomes
Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
Keywords: post-traumatic stress disorder, alcoholism, comorbidities, prolonged exposure therapy, Seeking Safety, veterans, heavy drinking, PTSD symptom reduction, treatment efficacy comparison, addiction treatment, trauma-focused psychotherapy, treatment tolerability, linear mixing model, treatment response heterogeneity
MeSH terms: Adaptation, Psychological, Adult, Alcoholism, Female, Follow-Up Studies, Humans, Implosive Therapy, Male, Middle Aged, Stress Disorders, Post-Traumatic, United States, United States Department of Veterans Affairs, Veterans, Comorbidity, Cognitive Behavioral Therapy, Outcome Assessment, Health Care

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Efficacy of Integrated Exposure Therapy vs Integrated Coping Skills Therapy for Comorbid Posttraumatic Stress Disorder and Alcohol Use Disorder: A Randomized Clinical Trial

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